Articles, Blog

We Have Solutions / The Opioid Epidemic with Arthur Evans, R. Kathryn McHugh and William W. Stoops

December 12, 2019

Good afternoon everyone good afternoon yes good I’m Arthur Evans and welcome now you see this sign that says psychology makes the impossible possible so that sounds like hyperbole right and I think it may be a little bit of hyperbole but the point of today’s session is to really explore how psychology can be applied to real-world problems to take on things that people may think are impossible but really or not if we apply what we know to those to those issues so I’m trained as a clinical community psychologist I’ve trained in experimental I’ve trained in other areas and I can tell you having worked as a case manager working in inner-city sections parts of New Haven Connecticut to running treatment programs to managing a billion-dollar healthcare system that in all of those positions I was constantly drawing on my training as a psychologist and constantly drawing on what I knew from the psychological literature and I can tell you that there were many many instances where people thought we were dealing with intractable problems where we were able to come up with solutions based on our not a lot of the knowledge that psychologists produce and so today we’re going to get an opportunity to talk about some of the challenges of the day and two in particular the emergence of artificial intelligence and the opioid epidemic we’re going to explore how psychology can help address those issues so if you look at the issues that we’re dealing with as a country health care immigration gun violence stress artificial intelligence and emerging technologies all of those are issues that psychologists are working in those are areas where psychologists are working and there’s really important information that can help us address those issues and I really believe that we must ruthlessly apply what we know to these issues how many of you saw Bryan Stevenson’s talk last night right pretty inspiring right now particularly a psychologist and so I think the challenge for us is how do we take on some of the issues that that Bryan Stevenson talked about and that many of us face so let me give you an example the issue of homelessness have you been in San Francisco you know a lot of homeless people here but if you’re in any major city in the country you know that homelessness is a challenge for most urban areas and most of us look at that and we think that’s just an intractable problem we’ll never be able to deal with and address the issue of homelessness so tonight I’m going to tell you what the solution to homelessness is I’m going to tell you how we as a country can solve the issue of homelessness I want you to lean in and listen carefully the way we solve homelessness in this country is we get people homes thank you now sounds a little glib but here’s the thing fundamentally that is the the way you solve homelessness but most of us know that there are challenges that many of the people who are homeless have behavioral health conditions in fact most people 90% either have a substance use disorder or a mental health challenge but most have both and so we know that there are barriers to making that happen but let me tell you how we and I did some work in Philadelphia with some colleagues there and reducing or getting people who were chronically homeless off of the streets and into homes and the term chronically homeless is an important term because we’re talking about people who had lived on the streets of Philadelphia for 10 years 15 years sometimes longer these people were really having some significant challenges and how we applied psychological research to address that issue so one of the things that psychological research tells us is that different things work for different people that sounds like a sort of simple thing but I can tell you as a policymaker that most times policymakers want to find a standard solution and apply it to everyone that’s just the way policy works in most instances but the literature and the research suggests something very different and so understanding that what we did was to create multiple pathways from the street into having a home so let me give you an example psychologists actually in in New York did some very interesting work and a model which he calls home housing first how many of you heard of housing first as a treatment strategy okay so for those of you who don’t know let me tell you how epically behavioral health systems and communities deal with homelessness the model works like this we have to go out convince people to come off of the streets which by the way can be sometimes take years and months get them into treatment treat them once they’re treated do rehabilitation and then help them get into housing that’s a typical way that people approach that issue well our colleague in New York said well what if we just help people get directly off of the streets into housing can we do that actually it works and actually this a lot of research that shows that it works so that was one of the pathways that we created for and that pathway works really well for people who have serious mental illness doesn’t work so well for people have serious addictions and I told you that many of the people were on the streets have serious long-term addiction challenges and so for those folks we said well if that pathway doesn’t work what is a literature tell us about how we can help those individuals and so one of the things for those of you who work in the field of addictions you know and I think this is also true of mental health is that the way we’ve constructed our health care system is on basically an acute care model meaning we go to treatment we assume that if we treat people and they leave that they are well well it turns out that addictions mental illnesses are more like chronic conditions it’s not like a broken leg is more like treating diabetes but our treatment models aren’t set up that way so when we change our treatment models to match what we know from the science that is treat addiction like a chronic condition ie having long term strategies for engaging people keeping people into treatment which costs more money on the front end but actually saves money on the back end we actually can get people who people people who traditionally would have come into treatment and left very quickly to stay and to move on to other options so by using the research using what we know of how these conditions work we’re able to actually get over an 8-year period about two thousand people who were chronically homeless off of the streets and into housing and we did that because we also partnered with people who were doing and funding housing so I think it’s a great example of how using what we know can actually help us to make progress on issues that we think are intractable so the big challenge is not necessarily that we don’t know how to solve problems the big challenge is how do we connect the dots between what we know and the challenges that our communities and our society faces often the people who have the challenges don’t understand or know that this information this knowledge exists and those of us who are producing that knowledge are often not connected to the people who are in need of that information so a big part of our challenge is how do we connect the dots so let me give you three examples of how I think psychology can be impactful in addressing some major issues of the day let’s take the issue of immigration we know that from decades of research that separating children from their parents is harmful from decades of research and we also know that the longer that that happens the the more damage that can happen and so it was no wonder that psychologists across this country were enraged when we had policies that really flew in the face of what we knew the impact would be on these families we also know from the literature about how to treat children who are traumatized we know the stress that is caused from immigration and from being a refugee we have psychologists are doing some wonderful work and documenting those issues and documenting how we can treat people and work with people and support people who are experiencing those kinds of situations and so the challenge for us is to make sure that we’re applying that knowledge to our public policy debate and discussion that’s one of the reasons that APA was so involved in that issue you probably saw and then just by show of hands how many of you saw a press story or any kind of information that APA was putting out on this issue I just want to get a sense from the audience so many of you saw that we were out there making sure that our perspective and psychologists were a part of the public debate on this issue and I think it made a difference we recited by lots of press we were called upon by members of Congress to do briefings we were asked and had the opportunity to talk to people in the administration and in fact just before I came to this convention we had the Health and Human Services asking us for our experts to help advise them on policies and practices regarding immigration so immigration absolutely an area where I think we have something very important to contribute we’re trying to do that and we have to look at ways that we can continue to do that take another issue that is one of the major issues of the day gun violence a hundred people a day will die by gun violence most of those people don’t die by mass shootings they die by suicide they die by domestic violence there are lots of different ways outside of what the public sees the psychologists we know that we also know the correlates of gun violence and we know strategies to help reduce gun violence we also know that we need more research in this area in fact there are federal laws that make it difficult to do the research that we need in this area do you know that we know more about motor act more vehicle deaths than we do about gun violence and gun violence deaths it’s by far it’s not even close so that’s something that we have to change something that APA is actually advocating on but when we apply what we know in terms of prevention of violence prevention of the use of weapons in domestic violence situations that those are things that we know can reduce their both the risk and the mortality associated with with gun violence now let’s give you one last one how many of you heard the term population health just by show of hands a lot of you most of you okay so for those of you don’t work outside of the healthcare arena one of the concepts that’s emerging and I think will really take off is the notion of population health let me just contrast that with the way we typically address health in the u.s. so our model of healthcare is based on the idea of the absence of illness is health so all of our money in healthcare in the United States goes to treating illness and in fact we will spend this year three trillion dollars on health care I mean you knew the number was that big three trillion with eighty and we spend that much that much money every year trying to treat illness he’s been very little of our health care dollar on trying to help people get healthy and stay healthy outside of treating illness so the idea of population health is look even though we spend three trillion dollars a year on health care we spend more money in the United States than anybody by far our health care outcomes are at the very bottom of industrialized countries and so the the idea of population health is well what if we had our goal being to raise the health status of the population of people we’re taking care of not just treating illness but really trying to raise the health status of people now that is good news for psychology because there is no way that we’ll ever be able to raise the health status of Americans without psychology let me tell you why if I were to draw you a pie chart of what accounts for our health status health care would be about 10% in that pie it’s 90 percent of other stuff the other stuff being things like environment genetics and the biggest part of that pie would be behavior so if you really want to affect people’s behavior or they’re out their health status it has to be through changing behaviors that are related to poor health that’s where we come in another major challenge that we face as a society and as a country that really requires us to be an integral part of the solution so what’s holding us back from making these connections connecting the dots between what we know and these real world problems I’ll give you a couple of suggestions about what that might look like so I think some of the challenges are us it’s our mental model of what it means to be a psychologist so I’ll give you an example so when I when I remember when I was training I remember this struggle that I was having early in my training as as a clinician where I understood the social ecological context of the people I was working with and I knew that as a psychologist my goal or my role was to treat the illness that people were walking in with and my mental model of what it meant to be a psychologist required that I ignored the social cultural context of people and focused on the symptoms of the person sitting in front of me so for the person who was depressed who had lost their job well you know maybe somebody else took care of that but you know my job was to deal with the symptoms when the reality is I help the person get a job probably be a lot better than doing psychotherapy with them so the point is that sometimes we can sort of limit what we think our interventions are by how we view what our role is and when we’re able to get out of that and be think creatively get out of the box we’re able to bring to bear solutions that we might not otherwise bring but part of the problem is also how the public sees us and one of the biggest challenges I think we face is that the public sees what we do is being very narrow being very limited to mental health you’re going to hear a discussion in a moment about the opioid crisis and I can tell you as someone who’s worked in that field for 20 years 25 years that many of the issues are clinical but many of the issues have to do more with IO psychology and selection or they have to do with how we think about messaging our areas of social psychology so many of the challenges that we face really have solutions that span the whole breadth of psychology so what we’re going to do today is talk to some experts in various areas and get their view on how our field can contribute to some of the challenges that we face we have three incredible talks that are going to demonstrate this the first up we’ll be on opioids and so can you welcome and join me in welcoming dr. Catherine McHugh and dr. William Stoops great thank you for for joining us thank you for having us okay good so I’m gonna start with maybe describing what you see is the problem and then some of the ways that psychology you think can help address some of those problems sure I think one important point here is this is not one problem this is not an opioid use disorder problem this is not simply a pain problem there are many problems in better than the some of which you just referenced before things like homelessness we know that the opioid crisis has particularly impacted areas of the country even though it’s touched pretty much every area particularly heavily in rural areas areas with high levels of poverty areas with poor social connectedness not a lot in terms of social organizations where people feel connected to so this this really as many problems and these problems are all things that psychology addresses ranging from stigma which I think we’ll talk about a bit to treatment and clinical intervention to IO social determinants of health it really touches every element of the field so I think you know the thing that I would add you know I come to this as a perspective as an experimental psychologist and I’ve said this numerous times I think of psychology as sort of the original translational science right like so we are the perfect group of individuals to address this to help to address we certainly cannot do it alone we need to partner with others but we need to be a big piece of that puzzle to address the multi-faceted nature you know we need to be thinking about the psychopharmacology we need to be thinking about you know behavioral interventions that we’re developing we need to think about how we train a workforce and how we train a workforce in recovery and I think that the breadth of psychology that’s the beautiful pieces we can we can speak to all of that so we’ve just heard that the CDC is expecting the opioid crisis to actually get worse before it gets better at least the data is continuing to trend up despite the public attention that we’re paying to this so what would you put at the top of your list in terms of what we should be doing to address this issue if you could tick off maybe two or three of the top things that we could be doing that you think would bend the curve or help us to be bent the curve on this issue so you know I think something that’s important if we’re talking about you know opioid overdose you know that you know with that that’s sort of the measure that Americans are using to to you know to speak about the magnitude of the problem and of course it is a huge issue we have proven ways to prevent opioid overdose or to intervene an opioid overdose I read that there was an opioid overdose outside the convention center yesterday and psychologists helped to intervene so you know I think that something that we will need to do is increase access to those overdose prevention so whether it’s narcan or whether it’s having individuals on medication assisted treatment and psychology can help bridge those gaps and have that access and and you know whether its messaging the public about it might be a good idea for you to get trained with narcan because you’re gonna you you there’s a chance you’re gonna witness narcan an overdose that that’s something that would be really important to me I think I would say a couple things one is prevention which is something that that psychology does well and we don’t talk nearly enough about if if we can catch someone if you think of the different touch points along the spectrum of opioid misuse and opioid use disorder that we know there are certain markers that once you hit that marker things get a lot worse so once you go from occasional opioid analgesic use to more regular use once you start going to intranasal use once you switch over to heroin use at each of those points prognosis worsens dramatically so if we can catch these things early if we can catch them in adolescence and intervene at that point we’re giving people a much better option forward I would say the other thing in terms of workforce development as a clinical psychologist we need to be doing better in terms of every clinical psychologist should come out of their training knowing something about addiction and being able to recognize that I think that’s tremendously important because even when the curve does start to bend on opioids we will have another addiction epidemic of some sort whether it’s stimulants whether it’s something else so I think that this is an issue both for now and for the future so you said something that’s kind of interesting and intriguing so we know that what’s driving the current opioid problem is that most people are starting on prescription medication and then they’re switching sometimes they’re switching because their physicians abruptly stop their medication when they find out that they might have a dependency and then that moves them very quickly into using illicit drugs sometimes it’s other processes you talked a little bit about how can psychology help address this issue how can we deal with or help deal with the fact that most people are starting with prescriptions and then switching over to more illicit medications or drugs actually part of that is better pain management I mean certainly psychology is is in a fabulous position to support around pain management behavioural pain management that in many ways is going to be most effective for chronic management of pain so starting people at that end is a tremendously large piece of it but also certainly in their implications at the regulatory level and how do we think about regulatory changes and what are the implications of for example proposals to limit opioid prescribing can we also think through what are the unintended consequences for pain and and what are we going to plug in there because if we start taking things away without plugging something else in that’s going to only make this problem worse and I think psychology is really well suited both from an organizational perspective to address that and also from a pain perspective to address it you know I think I thought that’s what I was thinking about too is you know the CDC guidelines came out about sort of very short term opioid prescribing and I think that that left us a little alerts because there are people with serious chronic pain who rely on opioids and we didn’t necessarily do something about that and then we’ve also got folks who then can’t access prescription opioids that they happen to be have a youth disorder you know so we you cut off you know Kentucky several years ago passed them and called House bill one that’s you know and that was a needed bill to sort of regulate prescription opioids but the unintended consequence was that heroin then came and in flooded the market and Herron was related heroin was laced with fentanyl and we’re seeing overdoses and we were seeing escalated dependence and because we didn’t come in behind that with increased treatment access either through behavioral treatment medication assisted treatment and better pain management for those folks colada list again they’ll others folks start with the legit pain condition if you don’t I think it’s brilliant plug something and if you don’t think about actually helping people aside from just cutting off the supply you you wind up with a worse problem than where you started so let me give you a challenge that I think we face ok so if you look at the the research there’s no research that supports the idea of using opioids for the treatment of chronic pain public probably doesn’t recognize that right so that’s one issue and then I think another misperception that the public has or maybe this is a misperception but just not understanding that one that there are pain management techniques and that psych ops are professionals that can help with that and I want to give you a quick example so I was talking to to federal officials high level I’m not gonna mention what they they were over but neither of them and these are health care people neither of them recognize that psychologists did paint so can you talk a little bit about levian about sort of the nature of the problem but also what some of the solutions are ie pain management by psychologists so you know I mean III think a great example here for pain management that we’re starting to really recognize is sort of the idea of mindfulness you know or you know sort of as a complementary alternative approach to managing pain and you know mindfulness is you know has its roots in psychology and so you know we have accepted mindfulness as a treatment for many many other things and I think that as a field we need to show the efficacy of mindfulness I think we need to do well controlled experimental studies demonstrating and there are data too of course to suggest it but we need to sort of do the next level up the bigger broader scale research and and and then also develop a way to then disseminate that to clinicians so that they can adopt mindfulness into their pain management practices you know I think I think I think we suffer from you know one individual does a research on this thing and then you know it doesn’t get carried anywhere and I think again because psychology is translational and it is broad we are well suited to communicate the findings to each other up the spectrum and back down the spectrum right you know I think that’s another beautiful piece is reverse translation take a piece take something that works and then take it apart and understand why it works because then that can help to refine the treatment that can help to advance our understanding of the brain mechanisms the behavioral mechanisms that are that are driving these effective approaches bill you mentioned that the dissemination word the the B word here which is a tremendous issue and one in which I also think psychology is really taking a lead in terms of dissemination implementation science I think there’s that field is growing rapidly and has enormous potential to get the word out there on what does psychology do I think one of the biggest challenges is you know if you are a pharmaceutical company that has a product you have a lot of reason to go out and market that because you you you bring that back if I am a pain psychologist with a shingle I can’t mark it at a large scale so finding a way for us to disseminate this information to government officials and I’m I’m a believer in pull demand I’m a stubborn clinician I imagine probably also some other stubborn clinicians in the room but I am a believer that we should be empowering the people who are going to be consuming services to walk in and say I hear mindfulness is useful I want this do you offer this and if you don’t I’m gonna go to the next person so I think there’s also really an opportunity for us to empower people to be informed consumers and to demand the highest quality care what are some other therapeutic techniques that you think we need to be a part of our armamentarium in terms of addressing this issue that we’ve talked about contingency management and other strategy sure sure sure so I mean something that we were talking about is the idea that you know we have pretty effective medications and you know psychologists I’d recognize and generally are not going to in general not going to be prescribing these medications but we also know that adherence to these you know to buprenorphine to methadone to naltrexone or not as high as we might like them to be and I think that although a psychologist might not be prescribing that they can be actively involved at helping folks be better adherent to those medications we talked about the example of contingency management which for those of you who aren’t familiar it’s very basic operant principle and that you are reinforcing a behavior that you want individuals to engage in and lots of time that’s abstinence from drug use that’s you know really how it’s been applied in our field but you can be very creative and apply it for any pretty much any target behavior but don’t you describe it so that people have an idea what does that mean I think sure sure so you know so let’s say we want our patients to be adherence to the naltrexone regimen you know and what you know you would do in essence is when somebody comes in for their long-acting vivitrol injection or when they’re you know when they pick up if they’re on oral naltrexone which no I’m not sure I’m crazy about but let’s say that that’s also treatment modality you you might look into that you provide some form of reinforcer oftentimes that’s money or vouchers for goods or services it it can be done relatively inexpensively there you know there’s something called a fishbowl approach where people can just literally reach into a fishbowl and it’s a piece of paper that says great job you showed up and you took your naltrexone today and that small amount of reinforcement increases the behavior and it’s relatively inexpensive still a challenge for you know many clinics to adopt but a very effective one in it and actually in the long run a contingency management approach because it is so effective saves you on costs the other thing in terms of tools in our toolkit that we haven’t talked about yet is supporting families yes which is a tremendous issue and even if you’re not someone working in the area of the fields where you’re dealing with folks with opioid use disorder in all likelihood we’re all seeing families that are dealing with it in some ways and and these are folks who are desperate in many ways they don’t know where to send people and I’ll see families at times who have spent $100,000 have emptied their savings have emptied their retirement to try to support their family members maybe even ending up in in some of these predatory treatment programs which are a tremendous issue now so supporting families around how do you talk to loved ones how do you talk to your kids about substances I think that’s something that really we all can do in a pretty fundamental way and this is an important way of impacting this crisis one of the things I recognize from my my own treatment pass is you know this issue of families is that often we’ll take people out of their context we’ll treat them in a treatment program and then we put them right back into the same context without any intervention and often the most powerful part of that that context is the family and so you know if mom or dad if the children understand how to deal with mom and dad when they are actively using now mom and dad don’t actively use it actually destabilizes the family and say that counterintuitive right but I can you talk a little bit about how you can think about family treatment as a really critical part in essential part to the treatment of of people who are having addictive disorders sure I mean the data speaks to this if you can involve families outcomes are enormous ly better and that that is sort of a closed case in terms of how much more effective treatments can be the challenges are twofold if you think of the traditional treatment setting you know if someone comes in and works that maybe they work with one of our prescribers and they come see me for an hour that’s maybe an hour and a half of their week and the rest of their week is full of interacting with friends and family maybe maybe not going to work all those other things so if we can engage the family to reinforce the messages that we’re reinforcing in treatment to be empathic and non confrontational to really support people in their recovery that now you’re impacting people where they are which is I think anytime we can make that translation make that jump even if I think of as a therapist my goal is to make myself useless is I want the person sitting across from me to be able to do what I do as soon as possible and not to need me because if they’re implementing that at home and if they’re implementing that with the support of family members that’s tremendous I don’t want them to have to come in and see me I’d rather that happen so it sounds like that there are some things that we know from the the research that could help improve treatment so you listen to the typical and I and I actually chaired a task force in Philadelphia on what the mayor should do around the opioid epidemic in the city but if you look at most of those task force reports at the very top of the list is we need more medication assisted treatment now there’s a lot of research support for that and I’m a strong believer in that but I think what you’re saying is that there are other things that could be just as important pain management as an alternative doing contingency management treating families those kinds of things how do we begin to broaden the conversation so that we include more of these other ways of understanding the problem and understanding the the solutions so you know i mean i think i think that psychologists and our colleagues who are do substance use disorder research have you know worked very hard to develop this evidence base you know i think that if you go to sort of one of our smaller conferences that is sort of more substance use focused there’s a lot of good work being presented here at APA but there are also smaller conferences where this is being done you can see how deep the evidence basis for the interventions that that work i I think again the issue is that we maybe as researchers have not done as great of a job of communicating that evidence base to the people who can actually implement the policy and I think that’s something that we’re starting to do we we you know the opioid epidemic has created a toehold for us to say we have been here all along doing this and look we’ve got evidence to show here’s what what can be used to treat these disorders and so we now got people listening to us you know we now got people who are asking our opinions who want to engage us and I think it’s a time to really strike and you know meet with policymakers at the state federal level I you know another thing I think about is you know sort of healthcare large healthcare plans insurance plans engaging those individuals was saying if you can adopt some of these evidence-based best practices into your health care plan into your HMO that’s a way to disseminate it you know they’re the ones who are paying the bills and if you can show it’s works and it’s gonna save them money that’s helpful and again I think I’ll talk a little bit more about money as someone who was a public payer for twenty years money does and and I think often in our conversations we have conversations about maybe treatment have efficacy and those kinds of things that speaks to one audience but I can tell you the audiences that I had to convince where the people were looking at the bottom line and so if you’re asking me to make an investment in these kinds of things what kind of data do you have that says that this stuff actually will save me money if I’m paying the bill sure so you know I mean I think that there are data to suggest that if you have somebody who is on medication assisted treatment so if you if you if you have engaged somebody in methadone or buprenorphine you decrease of course their likelihood of overdose which is one thing but you also decrease their likelihood of acquiring HIV or HCV because they’re not injecting drugs they’re not engaging in risky sex they’re you know and and HIV and HCV are very very expensive relative to a people Northmen prescription or a methadone prescription and so I think the data sort of on on adoption of those types of treatments really are compelling to say you know yeah you have to pay for this treatment but in the long run you are preventing and I think we’ve sort of talked about this if you can prevent stuff it’s a whole lot better and you know you were you were talking about this and you’re opening is that we don’t engage in a whole lot of sort of health promotion prevention we treat things after they’re a problem and yes of course you know opioid use to sort of presents itself then you treat it but you do then prevent other issues that are very costly one of the challenges and in any kind of cost considerations is but for substance use disorders for mental health in general you treat it you save money yeah Society for substance use disorders it’s even greater if you look at criminal justice savings for actually treating substance use disorders it’s it boggles the mind the problem is is who are you talking to in terms of cost savings right so a health system might not actually be all that concerned about criminal justice costs so there’s also the issue of where do the costs fall and what audience do we present this to you because the cost savings are tremendous but they’re spread across a number of different groups often times they’re longer term and if someone is looking at you know what money am I going to save in the next 12 months that’s inevitably going to be more modest so making that broader case I think it’s a little bit trickier right what would you tell I’m sure we have a lot of researchers and clinicians and audience what kind of advice or what would you like to say to folks who might be able to contribute to solving some of these problems challenges so I would say one big thing you again you mentioned workforce development I think anyone who is involved in training in mentoring and mentoring researchers and mentoring clinicians my goodness do we need to make folks more comfortable with this issue it’s like with any other issue if you don’t see it you’re afraid of it and I think opioids in particular is one that people are terrified of I hear all the time from people they say I don’t want to ask the question I won’t ask whether or not someone’s misusing and when I say why the answer is a hundred times out of 100 I don’t know what to do if I get the answer so I think workforce development and encouraging people and not just in clinical but in any discipline to think about this issue to if we can get training in addiction broadly across all of psychology if this can be really standard and how we think about things I think that will advance research agendas that will advance public policy agendas I think that’s enormous ly important the other thing I would add is we are all responsible in some ways for stigma is if we think about the language that we use the language that we expect other people to use we can make a difference in that and I think that’s something that everyone can do today that’s pretty tremendously important yeah I mean I completely agree that you know I one of the things I most admire about APA is that it you know it thinks about social justice and it thinks about how we treat people and it’s you know the idea of person first language APA is a leader in that you know when we go you know I was at an addiction conference in June and actually I should say the substance use disorder research conference in June and some of the language that was sort of used in terms of you know talking about people as addicts and those kind of things I was fairly appalled because I’m thinking we’re the specialists this is us and we should not be talking about it in in this stigmatizing way yet at APA we don’t have that as much and I think that that’s really an important thing that we need to think about the stigma and what we are doing you know we were talking earlier about you know maybe messaging and so I think one thing I would say is we need everybody you know you may not think of yourself as a substance use disorder researcher but you probably have something to offer if you’re a psychologist you know this is these are behaviorally defined disorders psychology is about behavior and is about rigorous study of behavior and about you know changing behavior we need your help we need your help with how we message things we were talking about I don’t know that anybody has seen them but the ads where people engage in self injurious behavior to get the opioids I don’t know I don’t even know who’s putting those out but they’re on in Kentucky I imagine they’re sort of a national ad campaign then they close with sort of a slide that says if you you basically this is may not be an exact quote but using opioids even five times can you know turn you into an addict just sort of what the language doesn’t that that that is not yet I think psychology can help people do better with you know some type of prevention message that isn’t fearful that isn’t stigmatizing and and and we need everybody’s help to do that you I’ve heard you all talk about incorporating peers into the treatment process can you talk about that and why you think that’s important and and let me preface it by saying that I have heard conversations where people have in our field have felt threatened by people who don’t have quote formal professional training so you know I mean I think I think the use of a peer navigator is really valuable and I’ve never thought of engaging peers is something that’s threatening to a psychology or psychologists I think of it as a as an as an addition and and as and as a valuable addition because what you know what I think a peer can do is present someone who is positively in recovery as you know as a as a as something that somebody can look to as that they can attain you know not all psychologists are in recovery you know and we talked about maybe not all psychologists or even trying to talk about these issues but appear who’s successfully in recovery can model that and can speak to that and I think that there’s real value there above and beyond what psychologists can do now we were also talking about hiring some of those individuals into you know health care settings can be challenging we have to do a lot of education with HR for example about you know the you know a peer probably doesn’t you know look like who you might typically hire at a major academic Medical Center or within a health care system but they can provide real benefit and so you just have to sort of educate and make sure that everybody’s on the same page about why it’s important to do this one thing to add to this from a research perspective and you know you talked about her bringing in peers recovery coaches is something that has really taken off and you mentioned sort of the research and policy being able to communicate with each other and this this is one that actually makes me a little bit nervous and this was one of the White House commission’s recommendations and it’s something in Massachusetts where I am where I think we’re putting the cart a little bit in front of the horse with this one where recovery coaches in in many ways so these would be peers who can support folks again sort of outside of the traditional treatment setting someone who might help somebody get to appointments somebody who might be able to help folks their high-risk situation tremendous potential here almost no research on it almost no regulation on it almost no training available on this so this is one where I actually think we need to be doing the research we need to be working with policy to make sure that you know how are we thinking about some of the challenges you’ve you’d mentioned before this issue of what do you do if one of your peers or one of your recovery coaches relapses themselves and how do you think about those kinds of challenges and and keeping the peers safe at the same time so I think there’s there’s tremendous benefit here I think there’s also tremendous research gap that really does need to be addressed and hand in hand with these policy changes what are some of the other areas of research that you think we need to really bolster why do we talk about medication assisted treatment and contingency management psychotherapy working and I think working absolutely but working in the same way that a lot of our other treatments work which is we tend to cap out at sort of a 50% treatment response rate for pretty much anything we do we don’t do much better than that and we have to do better than that so I think we have great treatments not nearly enough people can access them we need to get them out there we need to work with what we have but I think another big research push needs to be how do we get that 50 percent even to 60 percent how do we maybe get it to 70 or 80 percent some of that I think is prevention okay can we sort of slow that pipeline so there are fewer people who need active treatment but some of it is also you know how do we engage better behavior change strategies how do we get people medication compliant in a way that we can get above that we’re so stuck at that 50 percent response rate yeah you know and and and I agree you know it’s so disconcerting you know our the best we can do a lot of the time is 50 percent you know that’s why I was taking about adherence because I think some of that is also people are just not necessarily adherent to the treatment and so it’s not gonna work you know another you know I something that I don’t think we’ve talked so much about yet here on this stage is sort of what more basic research basic psychological research can do you know I think that we have really really smart psychologists who are doing research with rats and monkeys looking at psycho for psychopharmacology so you know as new medications are coming online either reduced abuse potential pain medications or novel treatment medications psychologists have been integral to all of that work to identifying you know is a drug and I have abuse potential is it gonna potentially be effective and I think that that that that’s important too I think that that that making sure we don’t forget about the basic end you know that that bringing that piece of science and so they can inform us about what we might want to advance or what we might not want to advance how we might think about sort of individual differences you know I think that a lot of that basic research and controlled human laboratory research can speak to individual vulnerabilities of you know this this might be a person who is more likely to progress as opposed to somebody else or you know this you know some underlying behavioral mechanism you know if they’re engaged with peers or if they’re engaged with you know a social network that uses drugs you know there’s really nice animal models of that that can speak to that and I think that we you know when we’re thinking more about the clinical and we forget about the important value that that more basic side adds to it to it as well do you want to say anything else about some of the research agenda and some other areas that we might want to pursue sure I would say to to just to comment on briefly again I do think stigma is an area where we could do more research both you know again this this is an issue where the disease is stigmatized and the treatment is stigmatized and I think recent and the treaters and you know and I think we have to think about that that many people don’t want to get into this field because you become stigmatized as much as the people who are treating yeah I think that’s that is a tremendous issue and to circle back to some of the social components of this one of the things that we found in some of our research is one of the major barriers to people engaging in treatment and getting better is if their entire sense of belongingness and their entire social system is embedded within substance use if multi-generational family substance use where all of somebody’s peer I will never forget one of the first people I ever worked with clinically we were talking about her getting back to work and I will never forget this I’m just learning at this point I have no idea what I’m doing and she sits across me and she said look you know if I told you to go out on the street and cop you know percocet and some klonopin and try to do this without any money in your pocket you you would have no idea what to do with yourself she said this is what I feel like with you telling me to look for a job and I think that is something where we really do need to be looking at some of those social considerations and working with folks around if we pull off the substance without changing some of these social components it’s not going to last yeah unsustainable that’s great so last comments what would you know which sort of the takeaway you’d like the audience to leave with on this issue so you know I mean I think that psychology alone is not going to solve the opioid crisis but psychology whatever term you want to use needs a seat at the table needs to be in the room and without it you know without thinking about psychological aspects of opioid use disorder of drug use disorders any intervention anything you try to do I think is going to fail because we we think about things that physicians don’t think about that social workers don’t think about and again I but I think we need all of us feel I mean we need all those people because we all bring an important perspective to this it’s such a big multifaceted problem I would I would say my take-home is be both hopeful and I think there are some indicators there are some positive indicators that opioid use is dropping in adolescence I think there’s a lot of reasons for hope and there’s a lot of reasons to say we have a long way to go and I think for both of those reasons this is an all-hands-on-deck issue that regardless of what your your sub discipline is within psychology we all have a role to play and I think that you know trying to get engaged in this is something that we all can do again even even if you’re not in the substance use disorder specialty setting we can all play a role in this and and I hope that this gave folks some ideas for how you might do that can we give dr. Stoops and dr. McHugh big round of applause and appreciation thank you so much thank you you

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